The dizziness may be triggered or worsened by visual stimulation such as bridges, driving a car, empty rooms, long corridors, large crowds of people in a store or restaurant cinema, television & computers.

The dizziness may improve or resolves during sport activities (bicycling, tennis) or taking some alcohol.

There may be a history of a significant attack of vertigo in the past or head injury.

When the patient is examined there is nothing abnormal.

The cause is not certain, emerging research suggests that it may arise from processing problems in the brain which control posture, multi-sensory information processing, or integration of spatial orientation and threat assessment.

Treatment
Diagnosis and Explanation
A clear positive diagnosis and explanation that the patient can work with. An understanding of how the nervous system has become sensitized can help desensitize it.

Vestibular therapy
Vestibular therapy works by desensitization. As the symptoms of have built up, most people avoid moving their eyes, neck and body as much as they used to. Physiotherapy and specific vestibular physiotherapy can be useful to help desensitize the nervous system and start to overcome ingrained patterns of movement.

Medication
a)PPPD
Amitriptyline 10mg, once a day at night for 4-6 weeks. (https://bnf.nice.org.uk/drug/amitriptyline-hydrochloride.html)

b) PPPD + Tiredness in morning :-
The SSRI citalopram 20mg in the morning (up to 40mg in morning ‪after 3-4‬ weeks) in patients with tiredness in the morning‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬
Contraindications : Epilepsy

c) PPPD + Anxiety and sleep disorders.
Mirtazapine (tetracyclic piperazinoazepine) in the evening, starting with 7.5 mg 0-0-0-1 tabl per day, increasing every week at first up to 15 mg or 30 mg in patients

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ABOUT

The London vertigo and dizziness clinic is the private practice of Mr Paul Montgomery, Consultant Ear, Nose & Throat Surgeon with a sub-specialty interest in vertigo, dizziness and balance problems. Mr Montgomery offers consultation and treatment in Central London, from King Edward VII’s Hospital and The Bupa Cromwell Hospital, Kensington.